Differential diagnosis of uterine bleeding
At the initial stage of diagnosis, the physician must rule out conditions not related to functional endocrine disorders. These include gynecological organic problems (benign and malignant tumors, uterine fibroids, endometriosis, inflammation, and trauma), pregnancy-related pathologies (ectopic or interrupted intrauterine pregnancy, placental polyp, retained products of conception), as well as extragenital diseases (diseases of the liver, blood, cardiovascular, and endocrine systems).
The examination is carried out in two stages:
- During bleeding: hysteroscopy with diagnostic dilation and curettage (D&C) is performed. The obtained scrapings are mandatorily sent for morphological examination.
- After bleeding stops: the degree of anemia is assessed (complete blood count) and blood clotting (coagulogram). Functional diagnostic tests are performed (measuring basal body temperature, calculating the karyopyknotic index, assessing "pupil" and cervical mucus stretch symptoms). Additionally, the hormonal profile is studied, pelvic ultrasound, hysterosalpingography, and instrumental assessment of the central nervous system (EEG, Echo-EEG, sella turcica radiography) are performed.
Clinical examination and medical history taking
A thorough interview helps identify a predisposition to dysfunctional bleeding (late menarche, juvenile bleeding in the past) or signs of organic pathology, such as cyclic painful menorrhagia pointing to fibroids or adenomyosis.
During a general examination, the physician assesses skin color, distribution of adipose tissue, presence of striae, hirsutism, and the condition of the mammary and thyroid glands. A gynecological examination outside of bleeding periods helps determine the estrogen balance:
- Absolute hyperestrogenism: the mucous membranes of the cervix and vagina are succulent, the uterus is enlarged, and the symptoms of mucus stretch and "pupil" are sharply positive.
- Relative hypoestrogenism: the mucous membranes are pale, and the severity of functional symptoms is significantly reduced.
Premature ovarian failure (POF)
The pathology occurs in women with a regular constitution and normal reproductive function for 10–20 years after timely menarche. The disease manifests as progressive atrophy of the genital organs and mammary glands without signs of central nervous system lesions.
The hormonal profile indicates persistent hypoestrogenism:
- Estradiol is sharply reduced (to the post-oophorectomy level).
- Gonadotropins are critically elevated: FSH is 15 times higher than baseline, and LH is 4 times higher.
- Prolactin is reduced by half.
- Basal temperature is monophasic, and the karyopyknotic index drops to 0–10%.
On ultrasound and during laparoscopy, the uterus and ovaries are reduced in size, and the endometrium is thinned. The ovaries appear "wrinkled," yellowish, without translucent follicles or corpus luteum. The most valuable diagnostic criterion is the complete absence of the follicular apparatus according to histology. A functional test with cyclic administration of estrogens and gestagens produces a menstruation-like reaction in 3–5 days and improves the patient's condition.
POF treatment and follow-up care
The main goal of therapy in ovarian failure is the prevention of estrogen deficiency. All patients are prescribed hormone replacement therapy (HRT) up to the age of natural menopause. Stimulation of the patient's own ovaries is strictly contraindicated due to health risks. For infertility treatment, exclusively assisted reproductive technologies are used—IVF with donor oocytes.
The dose of hormonal medications is individually selected by an endocrinologist under strict control of blood tests. Patients undergo follow-up examinations 1–2 times a year. Screening includes assessing the condition of the gastrointestinal tract, examination by an ophthalmologist and gynecologist. Before prescribing therapy, a detailed medical history is collected, taking into account the risks of thrombosis, cardiovascular disease, osteoporosis, oncology, and depression.
Adrenal amenorrhea
Menstrual function disorders can be the result of adrenal pathologies, which are divided into congenital, anatomical, and functional. For example, in Cushing's syndrome, excessive production of cortisol and androgens occurs, which triggers a cascade of endocrine disorders. Patients with detected tumor processes in the adrenal glands are mandatorily referred for further treatment to specialized endocrinologists.
To assess the signs of absolute hyperestrogenism during a gynecological examination, remember the rule of three "S"s: Succulent vaginal mucosa, Sign of the "pupil" (sharply positive), Sign of cervical mucus stretch.
Class and exam questions
What examinations are mandatory at the first stage of diagnosing uterine bleeding?
In the acute phase during bleeding, hysteroscopy with diagnostic dilation and curettage is mandatory. The obtained scrapings are sent for morphological examination to rule out organic pathology.
How do hormone levels change in premature ovarian failure?
Marked hypoestrogenism is observed: estradiol levels drop to values characteristic of the post-ovariectomy state. At the same time, gonadotropins (FSH and LH) rise sharply, and prolactin activity decreases by half.
Can ovulation induction be used to treat infertility in POF?
No, stimulation of the depleted follicular apparatus is completely inappropriate and hazardous to the patient's health. The only method to overcome infertility in this case is IVF with donor oocytes.
How often should one undergo an examination while taking hormone replacement therapy?
Adult patients should undergo follow-up check-ups 1–2 times a year. The examination includes dose adjustment under the control of blood tests, examination by a gynecologist, ophthalmologist, and assessment of the gastrointestinal tract.
What else to study on this topic
- Functional diagnostic tests: rules for measuring basal body temperature and calculating the karyopyknotic index (KPI).
- Instrumental methods for assessing the central nervous system and pituitary gland (EEG, Echo-EEG, REG, sella turcica radiography).
- Pathogenesis and clinical presentation of Cushing's syndrome in gynecology.
- Risk assessment before prescribing HRT: the impact of cardiovascular disease, thrombosis, and osteoporosis.
- Functional tests with cyclic administration of estrogens and gestagens.
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